Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes

Abstract

Background: Left ventricular assist device (LVAD) therapy is an increasingly viable alternative for patients who are not candidates for heart transplantation or who are waiting for a suitable donor. We aimed to determine whether there is an association between sex, race/ethnicity, insurance coverage, and neighborhood income and access to/outcomes of LVAD implantation. We further analyzed whether access to LVAD improved in states that did versus did not expand Medicaid. Methods and Results: Retrospective cohort study using State Inpatient Databases to identify patients 18 to 85 years of age admitted for heart failure, cardiogenic shock, or LVAD implantation from 2012 to 2015. Logistic regression analyses adjusting for age, all the sociodemographic factors above, medical comorbidities, and a hospital random effect were used to quantify odds of receipt of LVADs, as well as outcomes conditional on receiving an LVAD, for the sociodemographic groups of interest. A total of 925 770 patients were included; 3972 (0.43%) received LVADs. After adjusting for age, comorbidities, and hospital effects, women (adjusted odds ratio [aOR], 0.45 [0.41–0.49]), black patients (aOR, 0.83 [0.74–0.92]), and Hispanic patients (aOR, 0.74 [0.64–0.87]) were less likely to receive LVADs than whites. Medicare (aOR, 0.79 [0.72–0.86]), Medicaid (aOR, 0.52 [0.46–0.58]), and uninsured patients (aOR, 0.17 [0.11–0.25]) were less likely to receive LVADs than the privately insured, and patients in low-income ZIP codes were less likely than those in higher income areas (aOR, 0.71 [0.65–0.77]). Among those who received LVADs, women (aOR, 1.78 [1.38–2.30]), patients of unknown race or race other than white, black, or Hispanic (aOR, 1.97 [1.42–2.74]), and uninsured patients (aOR, 4.86 [1.92–12.28]) had higher rates of in-hospital mortality. Medicaid expansion was not associated with an increase in LVAD implantation. Conclusions: There are meaningful sociodemographic disparities in access and outcomes for LVAD implantation. Medicaid expansion was not associated with an increase in LVAD rates.

Racial and Sex Inequities in the Use of and Outcomes After Left Ventricular Assist Device Implantation Among Medicare Beneficiaries

“…Disproportionate differences by race in socioeconomic status and neighborhood deprivation 31 , 34 , 35 and reduced LVAD access for low socioeconomic status patients with HF are consistent with prior work. 36 , 37 These differences have resulted from systemic racism 33 and are associated with inequitable LVAD access despite no association with worse survival after LVAD. With the large racial disparities in wealth, 38 economically disadvantaged racial and ethnic minorities may be systematically withheld LVADs.…”

The impact of race on utilization of durable left ventricular assist device therapy in patients with advanced heart failure

“…This finding is consistent with other research that has been performed. Two prior retrospective cohort studies have also found Medicaid insurance to be associated with a decreased likelihood of LVAD implantation 1,11 . One of these studies was focused on one large academic hospital in a state where Medicaid provided limited reimbursement for LVAD surgery, the second study was multi‐institutional across 15 states where Medicaid reimbursement for LVAD surgery was variable.…”

Regional differences in presentation characteristics, use of treatments and outcome of patients with cardiogenic shock: Results from multicenter, international registry

“…CS treatment incurs substantial resource use and costs. MCS is usually not available in low-income countries due to cost restrictions, as well as long-term devices are almost always not affordable 25 . Inadequate access to MCS in majority of Non-European countries was apparent in our cohort.…”